Provider Demographics
NPI:1134283633
Name:WASHTENAW UROLOGY CLINIC PC
Entity Type:Organization
Organization Name:WASHTENAW UROLOGY CLINIC PC
Other - Org Name:JACKSON UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-782-7474
Mailing Address - Street 1:1010 BURR STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201
Mailing Address - Country:US
Mailing Address - Phone:517-782-7474
Mailing Address - Fax:517-782-2128
Practice Address - Street 1:1010 BURR STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-782-7474
Practice Address - Fax:517-782-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS056395208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3421964Medicaid
MI4108684Medicaid
1689762916OtherNPI
E86530Medicare UPIN
1689762916OtherNPI
MI3421964Medicaid